Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Tuesday, April 01, 2008

In the spirit of April Fool's Day we are, just for today, going to do the following in our ER...

1. We will see all comers regardless of their ability to pay, and regardless of whether they are drunk, high, lying, in the country illegally, have just murdered someone, or are coughing up blood after having smoked four packs a day for 50 years and have never seen a doctor before.

2. We will pull out all stops for all patients and do the absolute best medicine anywhere in the world for all patients mentioned in #1 and collect what we can from people with nothing to do with any of the patients in #1.

3. We will smile and respond 'yes ma'am' and 'yes sir' to patients and their families when they call us "asshole" or similar epithets and hit us, spit on us, and threaten our lives.

4. We will comply with all regulations and laws promulgated by the federal government to do all of the above without any funding to back up said rules, and with full exposure to liability for medical negligence for any of the patients mentioned in #1.

5. We will strive to comply with all JCHAO regulations, my favorite of which forbids us to eat at our work space (ostensibly to protect the health of the patient), but allows patients to eat in their rooms in the ER and upstairs.

6. We will surrender our power, gained by detailed expert knowledge and training, to people with clipboards who work 9 to 5 and haven't seen a patient in their lives, or, if they have, are no longer involved in patient care.

7. We will approach the art of medicine by applying a strict business model, striving for customer satisfaction with our patients, and look quizzically at each other since we have no idea how much particular tests or procedures cost, and have no expectation of being paid by any particular patient.

8. We will 'go paperless' and put dotting the "i"s and crossing the "t"s on the computer ahead of getting stuff done in a timely fashion for our patients.

9. We will dump more and more work on fewer and fewer providers (nurses, doctors, techs, and paramedics), and buff out that bottom line for our masters with clipboards and 9 to 5 jobs and zero clinical experience etc...

10. We will look the other way as our EMS system is abused by people calling 911 who "can't get a ride" to the ER or have that pesky 4am insomnia which is very uncomfortable for them.

11. We will happily put our helicopter crews at risk by flying at night and around dangerous obstructions to rescue the folks who plow their cars, drunk, into other cars, into crowds of people, or into bridge abutments, and cry a little each time a crew is lost.

12. We will see the same patient for the same complaint for the thirtieth time this year and spend thousands of dollars of other people's money looking for an imaginary diagnosis because the patient simply wants narcotics.

13. We will groan as clipboard people create new forms to supplement old forms and new requirements to supplement old requirements.

14. We will meekly comply as clipboard people and entitled patients demand quicker throughput in the ER while doing all of the above.

15. We will listen sympathetically to patients who are doctor shopping and tell us, "no one has ever done anything for me" while trying to make sense of their 500 page charts.

16. We will attend required meetings at 7am after working all night where freshly showered and manicured clipboard people in suits tell us that we need to work harder, faster, and better for less money.

17. We will look at the salaries of hospital administrators, often equal to or greater than ours, and put a grim smile on our faces while swallowing very hard.

18. We will wonder how an undergraduate degree cum laude from a top university, a doctor of medicine degree from a top-ten medical school, and a top-ten residency in our specialty of choice is worth less than an undergraduate degree in business from the State College of Northern Bumfoodle (with distinction).

19. We will attempt to resuscitate 96 year-old, severely demented nursing home patients because their family, not having seen them in 8 years, rushed to the hospital when they heard that 'dad was sick', and are demanding that we do 'everything'. We will crack the old man's ribs doing CPR, and wince with every 'snap', suck vomitus out of his oropharynx while we intubate him under chemical paralysis, and push tons of drugs into his veins in hopes that we get him back to his normal state of nothingness (with the family staring daggers at us).

20. We will walk into patient's rooms and smile at them while we wait for them to finish their cell phone conversation and order their super-expensive pregnancy test (that costs $5 at the drug store). We will then send their bill to the taxpayer.

21. We will break the spirit of brilliant and motivated medical students and residents as they shoulder the burden of 100 hour work weeks, an almost universal sense of patient entitlement, and we will pay the residents less than minimum wage.

22. We will give depositions to attorney's representing patients whom we may have harmed in some way and fret about our licenses and family and sleep and whether we really hurt or killed someone.

23. We will work shifting schedules that are akin to flying to Europe to work a few days and flying back here to work for a few days. Then we will take a few days "off", then repeat.

24. We will wonder why we chose to do this.

25. We will tell our kids not to go into medicine.

26. We will search for an exit and despair at our silver-plated handcuffs.

27. We will pay down our medical school debt way into our forties and then think about getting a nice house or car.

28. We will watch "House, MD" and laugh hysterically at that farce while knowing that people think that's what we do.

29. We will work a ten hour shift and realize, right at the end, that we are really hungry and need to pee really badly.

30. We will smile and feel good when that one patient in ten, thanks us for helping them.

31. We will consider going back to school to get a more valuable but much easier "advanced degree" so that we can get out of medicine and maybe retire at sixty.

32. We will pronounce a baby dead after trying everything we know and cry with the parents and cry later too. Sometimes the parents will be drunk..

33. Come to think of it, we'll just do this every day... I was mistaken, it's Groundhog Day.

54 comments:

We will be more than happy to thoroughly examine all five of your children for their "sniffles" just because you came in for a chronic toothache and were unable to have someone watch them. We cheerfully applaud you discipling them by allowing them to be running around the department and be loaded with Cheetos and Pepsi.

Ha Ha, we used to do Aprils Fools preops for the real asshololic residents. "Non english speaking 102yo morbidly obese quadrupple amputee, bad airway, MRSA, h/o malignant hyperthermia, sickle cell, HIV positive, for laser guided drainage of pilonidal cyst, allergic to narcotics and sedatives, and please use paper tape" To top it off we'd add a joke name like Seymour Hymen, and a room that didn't exist. Fun Times.

I can envision future generations taking a long, hard look at our society and shake their heads while muttering, "No wonder they went the way of the Romans. They had idiots running the place and failed to listen to those who produced."

Ugh. Now I'm depressed. How do you guys do it? So many people have no clue what doctors do.

Dont you just wonder how long it's going to go on before things just snap? It's like the system's been rigged and held together with duct tape for too long. Eventually it's going to full on break down.

Love #21. One time I had to explain to a cop (got pulled over, oops) that med students actually pay a lot of money to go to school and are not paid in any form for what we do. Took a minute for him to understand that I'm broke and very far in debt. Can't wait for my $2/hr residency!! (Ironically, waiters/waitresses in Texas make $2.15 an hour, not counting cash tips)

Wow 911, hand that revolutionary list of grievances to George III (or the Rominovs, depending on your leanings) and sign my name at the bottom. Every freaking day is April fools. You are the poet laureate of med blogs, my friend.

Monkey Girl, You have more faith in UNC than I do at this point. It will be a true champion that wins this year. Anyone could win it. I wish Davidson had managed to pull it out agains KU. How's my pinky?

Okay, fair enough. I have a counterpoint. I have been in the ER for the following:

1) bilateral kidney stones that needed to be removed by lithotripsy

2) very, very, very diseased gallbladder

3) miscarriage

I was rear-ended in an automobile collision and declined to be transported. Saw my primary care physician and requested a referral to a physical therapist. Was told that that was the "easy way out" and he prescribed Flexeril, some sort of codeine derivative, and massive doses of Tylenol. Eventually a month later he grudgingly wrote the referral for the physical therapy.

Oh, and also, I have taken my children to the ER because they have been in excruciating pain from

1) urinary tract infection

I took my child to the pediatrician, who promptly had my toddler admitted for three days for

1) rotavirus

So. Let me tell you what happens when you are a legitimate patient who walks into the Emergency Room, who would rather stick pins in her eyes than take narcotics.

Narcotics make my eyeballs itch. I can't sleep on narcotics. I get ferociously constipated and then I get depressed because I can't sleep. I fail to see the appeal. I don't want narcotics.

If I am in your ER it is because I am in excruciating pain, and I want you to make it stop. My doctor's office is closed. The pain woke me out of a sound sleep. If I go to my primary care physician with this kind of pain, there is absolutely nothing he will be able to do for me.

But what I find, is because I am a woman of childbearing age -- even though I have an advanced degree and bathe regularly -- while the folks up front do a "wallet biopsy" you guys biopsy me -- to see if I am really human.

You will do a pregnancy test even if I tell you that I am currently menstruating, then you will treat me like dirt until the pregnancy test comes back negative, because I am married.

If I am in pain, you will presume that it is PID, even if I tell you I am sexually inactive. Then you will treat me like dirt until the ultrasound reveals a kidney stone the size of a one-carat diamond.

If I am in pain, because I am a woman of childbearing age, you will presume that I have VD, or that I am pregnant, or have PID, or that I am in some other way some kind of dirt ball, even though I have come to your department sober, requesting Toradol and not Dilaudid.

I was not seeking drugs, my gallbladder needed to come out.

Oh, and, note to recovery room nurse: Right after you have your gallbladder out, just as you're coming out of anesthesia, you really do need additional painkiller. So telling me to "SHUT THE HELL UP!" really isn't useful. I'm crying because it really hurts. In fact, I have to crouch over and put my hands on my knees in order to breathe. Since I always come to the same ED, you can look in my chart and see that when I came here for the kidney stone I asked you for Toradol, so perhaps if I'm asking for something after you pulled my gallbladder out of my navel, you could get off your fat ass and get me something for the pain.

I realize that most of you folks hate your jobs, hate most of your patients, and don't want to talk to a member of the public unless they're spurting arterial blood or suffering from a full-blown heart attack.

But until you can tell those of us in serious pain from legitimately painful conditions that really require urgent medical treatment where we can go when it's Friday night and we have a kidney stone, we're going to come to your ER. Because kidney stone pain really, really, really, really hurts.

It would help those of us of childbearing age who bathe, are sober, and drug-free, and are asking for Toradol, if you would not automatically assume that we are pregnant by someone not our spouse, suffering from PID or VD, or seeking drugs, and talk to us like we are pieces of shit with legs, until at least the initial tests come back.

Signed, The Gallbladder Had to Come Out, and I Promise You I'd Rather Clean Up My Cat's Hairballs Than Come To Your ER, So Lose The Attitude

You asked me tonight "why not NP, or PA?"...and I think this sums it up. Every burned-out medic, doc, nurse, tech, hospitalist..we all should read this because this post is overwhelming, and it makes my throat hurt and my eyes burn, and my shoulders sag against the battles we are losing. And at the end of many shifts, I sit in the floor of my shower and I cry, both for the ones I lost and the ones I saved, both the nine week old baby and the ninety year old woman, neither of which we brought any justice to, one we should have saved, and one we should have let go...I don't want to further myself in this field, I spend too much time already crying in the shower while the scalding hot water washes the injustices and stupidity of the world away...I'm afraid if I stay much longer, the ignorance will seep into me and spread to my children.

anonymous (last), took me a minute to figure out who you are and now i know. God Bless you, you make my job enjoyable in little bits. hopefully this all this counts for something somehwere better. if not we are truly fools.

"TOBASH" southern Alabama slang term used primarily by resident physicians and nurses to indicate what they would like to do with a particularly unpleasant patient. T- AKE O- UT B- ACK S- HOOT in H- EADexample, "Dr. Drackman, theres a TOBASH in room 4"

14, 16, 17 and 18 are the best! Those apply universally- it seems there is always someone who has never done your job telling you how to do your job! thanks for doing what you do! Many people couldn't take it!

What I am angry about, asshole, is that before I got my gallbladder hauled out through my navel, I had to listen to a grossly-overweight, furious, pretentious, nasty, bitter, patronizing bitch of an ER nurse lecture me about how I can't possibly know whether I'm really pregnant and who sent the OB/GYN to make sure I really didn't have suppurating VD and in general acted like she hated life, and me, and herself, but not necessarily in that order.

In other words, you people -- some of you -- have your own, shall we say, isshers, which you visit on members of the public who aren't spouting blood to the ceiling or are in total cardiac arrest.

The nurse could stop talking to me like I was a piece of shit on two legs...I wasn't the one who could stand to lose 50 pounds, and I wasn't there because I wanted to be there, and no, I wasn't pregnant, and no, there was no way in heaven's name that I had VD. No, there was no way that this nurse was pregnant or had VD either, because she was such a perpetually angry, resentful bitch that she actually demanded that the anesthesiologist walk me to the bathroom because she was too busy. I promise you she hasn't had a date recently, and perhaps that was her basic problem.

I was telling her where it hurt and what was wrong, and she couldn't hear me.

Same thing with the kidney stone situation. I was pissing red, folks...I was puking it hurt so much. But as much as you folks are just so awesomely brilliant that you not only know about medicine, but you know about everything else too, I really didn't want to be there. It's just that nothing else made me stop pissing opaque blood and puking from the pain.

But until I pissed into the cup, the nurses were calling the OB/GYN and demanding pregnancy tests.

Yes, I have heard about the 400-pound people that somehow make it into the third trimester without knowing they are pregnant.

I am a size 2. And I am pissing blood and puking. And I told you that both things were taking place. And yet the nursing staff couldnt' decide whether I was human or not until after the ultrasound. Then, I got to be treated like a human being.

Before that point, I was either presumptively an adulteress with PID or a drug-seeking malingerer.

Some of you folks just don't fucking listen. You've gotten it all figured out already.

You want to bitch about the asshole with the hangnail that calls the ambulance? Okay, tell the bitch in the recover room that after a cholecystectomy you're supposed to provide pain relief.

dear anonymous, again, i'm glad you are well. you seem like a nice person and really on the right track. best wishes to all your family and friends and please continue to visit and spread sunshine and happiness everywhere you go.

Layin' into those business majors pretty hard there, nine one one. For April 1 in the lab today, somebody slipped high above the door an official Stockholmy looking announcement about the most recent Nobel Prize: "The Nobel Committee, after heated and thorough deliberation, has chosen to bestow upon Terry J. Peters, MBA, South Jersey College of 'Office Solutions,' the 2009 Nobel Prize in Physiology and Medicine for his timeless commitment and raptuous insight concerning the treatment of every disease known to mankind. From his middle management position at a mid sized regional hospital, and through the transcendent brilliance of his 6 year, "Let's Make the Voyage Together- A journey to the highest quality of care in every single aspect of health service across the entire continium of patient care while fostering a culture of Service Excellence!" philosophy, Mr. Peters has lifted the spirits of millions, setting free an overarching panacea to which we all owe our very health. Thank you, Terry."

I think that in addition to holding an MBA, some of these hospital admins. should have to be poet laureates. It seems a natural prerequisite, as those people find the most creative ways of telling you to drop the soap, take it, and not to make a peep. Oh, and scrub the floor while you're at it.

That would've been a punctual way to end this post, but I almost forgot: Thank You Doctors, those that blog here, those that just stop by, and I guess thanks Pathologists too. I have an odd feeling that there is a large, largely silent majority that greatly appreciates (even if they don't fully comprehend) the sacrifices upon sacrifices that the profession demands. We pay our bills. Goodnight!

What anonymous #1 doesn't realize is that the human race is prone to lying. Shocking, but true, and an ER doctor, who has no previous relationship with a patient, but does have a significant amount of liability for missing key diagnosis has to go through the regimen for ALL female patients of child bearing age. Even in my small town, where the ER doctors would know me personally (and I hope believe me), I would have no problem submitting a urine for a pregnancy test, despite knowing that I would not be pregnant. There is no litmus test for being truthful, and ER doctors have to deal with that.

Point 19. Well taken. I have heard that we do not have to deliver medically futile care, but given the liability no doctor will not go through the motions, even though it feels awful to beat on a body that is already nearly in the grave. When will our society come to terms with the fact the dying is a natural end to the living process? We can not cure everything.

In our system, there was a patient with end stage cancer with no other reasonable therapies available (had been to the big referral centers who concurred) who was hospitalized repeatedly with complications of said cancer. Despite extensive conversations with multiple physicians the patient and family demanded that everything be done. On the last hospitalization the patient was intubated. The patient became septic (likely from tumor eating through bowel), went into renal failure and required on going pressor support for days. When she coded, since death will happen eventually despite the wishes of the family, the ER physician responded (in our small hospital that is how it works). After appraisal of the situation, the ER physician spoke to the family about letting the patient go (assuming, I think, that the primary doctors hadn't already tried on a daily basis). He came back to run the code because "it's like they don't even seem to realize that the patient is sick."

That hospitalization ate up thousands and thousands of dollars of what everyone on the case felt was futile care; however, given the palpable anger of the family no one felt comfortable in denying care for fear of lawsuit.

Society needs to take a look at this. Physicians are not god, we can not predict when someone will live or die, but we have a pretty good idea in some situations. There is a point where care is futile.

On some other blog, I read about an ethics case regarding a family refusing to withdraw care on a basically brain dead patient because of "religious" beliefs. A patient with absolutely no chance of meaningful recovery, on a ventilator with a feeding tube. How about having the church pay the medical bill? Since when did it become a sin to die?

OK.....I seem to be on a soap box and I may be about to step on toes....but in a society that has a limited pot (in part because we like to spend so much on other activities) we need to look at "doing everything" all the time. I don't have a great answer, but I know the system is broken and there needs to be more talk about some of the tough decisions.

I am not a physician myself, but to sympathize with you guys- it *has* to be irksome for someone to walk into your ER asking for a specific med, much less a narcotic. WTF? The doctor hasn't even had time to see you or make a diagnosis and you're already demanding drug A or drug B.... to the anonymous poster- yes I understand you had legitimate problems- but did you ever consider how you come off coming in and demanding meds?

anon #1:I completely agree with everything you say. Thank you for enlightening these heartless bastards. You are an inspiration to patients and women everywhere.

Oh, April Fools, BITCH! Eat a fucking cupcake and plump up that flat size 2 ass (the pissing blood thing turns me on, don't get me wrong.) You sound like a real charmer. I'm sooooo sorry that you a) went to the ER, b) were appropriately diagnosed and treated, and c) were temporarily annoyed by a mildly overweight nurse. Wow. Sounds like a HORRIBLE experience. You convinced me: doctors really are jerks.

Take your whiney, entitled, Karen Carpenter body and try to treat yourself next time you are "really" sick. (please refer to prior photo of Hillary Clinton and paste your photo over her face)

fascinating discussion - I think doctors overestimate the number of patients abusing narcotics, abusing the system, or abusing the right to be seen in an ED. Most patients aren't stupid, just have no where else to turn for immediate answer to their questions - somthing Americans value a lot and I think some do not feel responsible to pay for this service and/or terribly underestimate what it costs to provide that service. The abusive patients on drugs and alcohol ruin it for the patients who are not. The few actual devious drug seekers ruin it for those who have legitimate pain, with or without a findable cause. How to stay happy and cheerful in a place where you are expected to "take it" and dish out love at every corner while being the smartest person in the world and never missing a diagnosis is something I have not figured out. However, each individual patient should not suffer the woes of the world - SHED the burden of the day, the last patients problem, and societies downfall when you walk in the room with ONE patient adn JUST you and do what one human should do for another (keeping in mind that I don't mean you have spread flowers and love at every situation). The actions for that patient should be about that patient and not the rest of the issues that he/she has nothing to do with that day.... those are our, yours, mine, societies problems to fix. I suspect something will eventually fall apart and fix / destroy this issue all together... When there's no pie, no one gets a piece...grin

I know this isn't the point of anonymous' rant up there, but what's the big deal about taking a pregnancy test? Right before my radiation I had to take one and I had just finished my period the day before AND also had my tubes tied. The radiation guy is a family friend of ours, and knew me well and still had to ask me to take one. How would a doctor you just met have any idea whether you were telling the truth or not?

Back in the 80's before PFP occasionally doctors would take their own x-rays. I remember wheeling a patient into radiology and the surgery intern playing with the KeV knobs to document free air. The 11-7 x-ray tech was doing something else, and taking x-rays isn't exactly rocket science. A downside was the occasional KUB with a fetal skeleton right smack in the middle. It was usually left hanging for everyone to laugh at till the next idiot took one.

Wow, I always come to parties late. Maybe she would have preferred the gall bladder surgery where "they haul out" your gallbladder through a large incision instead of a little bitty incision that heals in about 10 days. I've never been more thankful for my doctors than after reading all her vitriol and ungratefulness.

Anon - I do not believe you a nurse told you to "shut the hell up." I simply do not believe you. You are a nasty little foul-mouthed troll with nothing to add to this discussion except your own unpleasantness.

Do you ever wonder why karma has thought to punish you with kidney stones and gallbladder pain? It's because you're a little twit.

Did anyone else notice that anon used a lot a big medical words for a layperson? Twit, are you munchausening yourself, and that's why you're so defensive and obnoxious?

I was thinking the same thing, Michele. I would love to meet Skinny-Ass Anonymous in a clinic. I would use so many big, long, medical terms her skinny head would be spinning. Put that biatch in her place! That would make my day. Skinny, move to Canada. Better hockey up there, too.

I don't think the anonymous poster's issue was so much the fact that she was required to take a pregnancy test, but that it is so easy for nurses, PAs, and docs to talk down to patients. I've only needed to go to the ER once (broken wrist), but even in normal office appointments, it's not uncommon for medical personnel to be insultingly patronizing. I, too, went to school for a long time, endured a lot of poverty, and pay large student loan bills. I am paid far less as a college professor than most underpaid docs. I don't go into anyone's office demanding drugs, but I've certainly been talked to as if I were chronically dishonest or stupid.